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Medicine and Social Justice will have periodic postings of my comments on issues related to, well, Medicine, and Social Justice, and Medicine and Social Justice. It will also look at Health, Workforce, health systems, and some national and global priorities

Sunday, May 26, 2013

Medicaid expansion will leave out many of the poorest: What is wrong with this picture?

In States’
Policies on Health Care Exclude Some of the Poorest, in the New York Times on May 25, 2013, Robert
Pear describes how this bizarre situation has come to pass. Basically, it is
because the programs established by the Affordable Care Act (ACA) of insurance exchanges and federal subsidies for low-income people,via tax credits, was never the ACA’s plan for the lowest-income Americans. They were
supposed to be covered by expansion of the Medicaid program, a federal-state
partnership that covers some poor people and varies widely, both in terms of
who is covered and what that coverage consists of, from state to state. Recognizing
that, coming out of the “Great Recession”, many states were strapped for money,
the ACA also included a provision that the first 3 years of the expansion would
be paid entirely by the federal government, and that the feds would pay 90% of
the cost thereafter.

This, however, was not sufficient inducement for many states
to agree to expand Medicaid. They might have if the Supreme Court decision that
found the ACA constitutional had not excluded one provision – that, unless the
states’ expanded Medicaid they would lose all their current Medicaid funding.
The result was the decision in many states to not participate in Medicaid
expansion, thus effectively leaving out the mechanism for covering the poorest;
tax credits were designed to provide subsidies for those who earned from the
poverty level to 4 times the poverty level ($11,490 to $45,960 for a single
person) with Medicaid expansion covering those below it. However, many states
(virtually all Republican-controlled, although not all those that are
Republican controlled) have opted out of this program, leaving those below the
poverty level uncovered. The head of the Louisiana Primary Care Association
notes that “If the breadwinner in a
family of four works full time at a job that pays $14 an hour and the family
has no other income, he or she will be eligible for insurance subsidies. But if
they make $10 an hour, they will not be eligible for anything.”

While these states
may not have more than half the country’s total population, they do, according
to the Times, have more than half the
uninsured (they include Texas, the nation’s second most populous state, which
has an uninsured rate of about 30%, and Florida, the fourth most-populous,
whose legislature has decided not to expand Medicaid despite the support of
Republican governor Rick Scott for expansion). “The
Congressional Budget Office estimates that 25 million people will gain
insurance under the new health care law. Researchers at the Urban Institute
estimate that 5.7 million uninsured adults with incomes below the poverty level
could also gain coverage except that they live in states that are not expanding
Medicaid.”

The state “featured” in Pear’s article is
my home state of Kansas, possibly because of the willingness of the state’s
insurance commissioner, Sandy Praeger (pictured here with Secretary of Health
and Human Services Kathleen Sebelius, who, the Times does not indicate, was formerly Governor of Kansas, and,
before that, Praeger’s predecessor as insurance commissioner), to discuss the
situation. Kansas, historically not one of the more generous states for
Medicaid, “…provides no coverage for
able-bodied childless adults. And adults with dependent children are generally
ineligible if their income exceeds 32 percent of the poverty level.” Thus,
Ms. Praeger said, “In most cases, she
said, adults with incomes from 32 percent to 100 percent of the poverty level
($6,250 to $19,530 for a family of three) ‘will have no assistance.’ They will
see advertisements promoting new insurance options, but in most cases will not
learn that they are ineligible until they apply.” Whoops. Gotta fix that.

Or not. There is no plan, in Kansas, Texas, Florida, or any
of the other states not opting for Medicaid expansion to help to cover these
people. Most of the arguments you will hear against doing so cite “costs too
much money”, but this is, simply, baloney. The governors and legislatures
currently running these states do not, actually, believe in covering anyone
(except, of course, themselves and their friends). They believe this is “socialism”.
What they believe in is cutting taxes, particularly on the wealthiest
individuals and corporations, which Kansas has aggressively done since
Governor Brownback was elected in 2010. The ostensible argument, from the
governor, is that low taxes will lead to greater business growth, which will
benefit the economy, and help to balance the budget. The first is your basic “trickle
down”, proved wrong in every instance since it was first made popular in the
1980s, and the second is a negative tautology – even if business does grow, the
extremely low tax rates will make balancing the budget very hard. Indeed, this
year Governor Brownback is stumping the state to drum up support for not cutting the higher education budget,
but this seems to be falling on deaf ears in the legislature, which sees such spending
cuts as yet another opportunity to cut taxes.

Praeger, as insurance commissioner, does not make the
decision about Medicaid expansion, but her office is responsible for informing
the public about its opportunities to gain insurance on the exchanges (that
will be federally-run, because Kansas has also opted out of running its own)
and also informing those “poorest of the poor” that the ads for coverage will
not be for them. It is obvious that she feels very badly about it; this former
state senator and mayor of Lawrence, and former chair of the National Association of Insurance Commissioners (NAIC) is a person with a heart and a concern for
people (yes, Virginia, there are Republicans with a heart, and Kansas used to
be full of them!). The insurance commissioner does make some decisions;
Sebelius, in 2002, blocked the sale of Blue Cross/Blue Shield of Kansas to the
for-profit Anthem, stating it would not be in the best interest of the people
of Kansas. Many credit that very popular decision for helping her to win the
governorship later that year (yes, Virginia, we sometimes elected Democrats as
governor!).

It is way too early to know how these decisions will affect
elections at either the state or national level. The Times article indicates that “Administration
officials said they worried that frustrated consumers might blame President
Obama rather than Republicans like Gov. Rick Perry of Texas and Gov. Bobby
Jindal of Louisiana [and one might add Kansas], who have resisted the expansion of Medicaid.” However, and very
unfortunately, the poorest of the poor do not vote in high numbers. Perhaps the
opposite will happen, with those slightly more well-off, who vote at slightly
higher rates, crediting the Obama administration for their new coverage, and
blaming the state governors and legislatures.

And, of course, this does not even take into account
undocumented people living in the US, many of them the breadwinners for
families that are composed of citizens, “legal” and “illegal” members. Children who were born here are citizens (and
eligible for programs such as Medicaid and the State Children’s Health
Insurance Program, S-CHIP) while often their parents are eligible for nothing.
This is not the way to improve health, or to foster family values. But it is
consistent with another, anti-immigrant, agenda.

Other first-world countries cover everyone. Not some, many
or most people. Everyone. They do it in different ways: Britain has a National
Health Service, Canada a single-payer health system which is the government,
Switzerland a multi-payer (private) system with a required benefits package and
pricing structure. Other countries, Japan and Taiwan, France and Germany, do it
differently, but they all cover everyone. We could too.